The use of selectiveserotonin reuptake inhibitors (SSRIs) is an independent risk factor for bleeding events. Antidepressants and oral anticoagulants (OACs) are often prescribed together as depression and anxiety often coexist with cardiovascular diseases, atrial fibrillation and thromboembolic disorders. Serotonin is released from platelets in response to vascular injury, promoting aggregation. Inhibition of serotonin transporter (responsible for the uptake of serotonin into platelets) can lead into a reduced ability to form clots and a subsequent increase in the risk of bleeding. Direct oral aticoagulants (DOACs), rivaroxaban, apixaban and edoxaban are primarily metabolized via CYP3A4. The co-administration of antidepressants with inhibitory effects on CYP3A4 may theoretically interact with them.

Presentation of a case of upper gastrointestinal bleeding after initiation of Apixaban in a patient taking Sertraline and literature review.

We carried out a literature review in Pubmed electing those articles focused on bleeding risk between newer direct oral antigulants and selective serotinin reuptake inhibitors.

A 66-year-old woman sought medical assistance for generalized ecchymosis and melena. She was diagnosed with atrial fibrillation treated with apixaban 7 days ago. Concomitant treatment between apixaban and sertraline was the possible cause of upper gastrointestinal bleeding and ecchymosis. We had to switch sertraline into vortioxetine (with less dregree of serotonin reuptake inhibition) and add proton-pump inhibitor (Omeprazole) in order to decrease the risk of bleeding.

SSRIs increase the risk of gastrointestinal bleeding, much more in case of concomitant use of oral anticoagulants. If SSRI use cannot be avoided, monitor closely and prescribe proton pump inhibitors.

Individuals on anticoagulation therapy are at increased risk of bleeding, including epistaxis. There is a lack of available reversal agents for novel oral anticoagulation therapy.

This paper reviews the current literature on epistaxis in the context of novel oral anticoagulation use, in order to recommend guidelines on management.

A comprehensive search of published literature was conducted to identify all relevant articles published up to April 2019.

Patients on oral anticoagulation therapy are over-represented in individuals with epistaxis. Those on novel oral anticoagulation therapy were more likely to relapse compared to patients on classic oral anticoagulants or non-anticoagulated patients. Idarucizumab is an effective antidote for bleeding associated with dabigatran use. Recommendations for epistaxis management in patients on novel oral anticoagulation therapy are outlined.

Clinicians need to be aware of the potential severity of epistaxis and the increased likelihood of recurrence. High-quality studies are required to determine the efficacy and safety of andexanet alfa and ciraparantag, as well as non-specific reversal agents.

Epistaxis is the most common ENT emergency. This study aimed to assess one-year mortality rates in patients admitted to a large teaching hospital.

This study was a retrospective case note analysis of all patients admitted to the Queen Elizabeth University Hospital in Glasgow with epistaxis over a 12-month period.

The one-year overall mortality for a patient admitted with epistaxis was 9.8 per cent. The patients who died were older (mean age 77.2 vs 68.8 years; p = 0.002), had a higher Cumulative Illness Rating Scale-Geriatric score (9.9 vs 6.7; p < 0.001) and had a higher performance status score (2 or higher vs less than 2; p < 0.001). Other risk factors were a low admission haemoglobin level (less than 128 g/dl vs 128 g/dl or higher; p = 0.025), abnormal coagulation (p = 0.004), low albumin (less than 36 g/l vs more than 36 g/l; p < 0.001) and longer length of stay (p = 0.046).

There are a number of risk factors associated with increased mortality after admission with epistaxis. This information could help with risk stratification of patients at admission and enable the appropriate patient support to be arranged.

To examine the choices Canadian family medicine residents make for oral anticoagulation (OAC) for patients with nonvalvular atrial fibrillation (AF).

AF increases the risk of strokes. An important consideration in AF management is risk stratification for stroke and prescription of appropriate OAC. Family physicians provide the vast majority of OAC prescriptions.

We administered a survey to residents in multiple Canadian family medicine training programmes. Questions explored the experiences and attitudes towards risk stratification and choices of OAC when presented with standardized clinical scenarios. In each scenario, a novel oral anticoagulant (NOAC) would be the preferred treatment according to the contemporary Canadian and European guidelines.

A total of 247 residents participated in the survey. Most used the congestive heart failure, hypertension, age ≥ 75, diabetes mellitus, stroke or TIA (2 points) (81%) and congestive heart failure, hypertension, age ≥ 75 (2 points) or age 65-74 (1 point), diabetes mellitus, stroke or TIA, vascular disease including peripheral arterial disease, myocardial infarction, or aortic plaque, sex (female) (67%) risk stratification schemes while the preferred bleeding risk stratification scheme was hypertension, abnormal liver or renal function, stroke, bleeding, labile international normalized ratio, elderly (age ≥ 65), drugs or alcohol (84%). In the clinical scenarios, residents generally preferred warfarin in favour of NOACs, independent of training level. Residents ranked the risk of adverse events and the cost to the patient as their most and least important consideration when prescribing OAC, respectively. Therefore in patients with nonvalvular AF, Canadian family medicine residents prefer warfarin in comparison with NOACs despite the latest Canadian and European guideline recommendations. This knowledge gap may be enhanced by multiple factors, including a sometimes magnified fear of adverse events and a rapidly changing landscape in stroke prophylaxis.

Patients with venous thromboembolism (VTE) (deep vein thrombosis [DVT] and pulmonary embolism [PE]) are commonly treated as outpatients. Traditionally, patients are anticoagulated with low-molecular-weight heparin (LMWH) and warfarin, resulting in return visits to the ED. The direct oral anticoagulant (DOAC) medications do not require therapeutic monitoring or repeat visits; however, they are more expensive. This study compared health costs, from the hospital and patient perspectives, between traditional versus DOAC therapy.

A chart review of VTE cases at two tertiary, urban hospitals from January 1, 2010 to December 31, 2012 was performed to capture historical practice in VTE management, using LMWH/warfarin. This historical data were compared against data derived from clinical trials, where a DOAC was used. Cost minimization analyses comparing the two modes of anticoagulation were completed from hospital and patient perspectives.

Of the 207 cases in the cohort, only 130 (63.2%) were therapeutically anticoagulated (international normalized ratio 2.0–3.0) at emergency department (ED) discharge; patients returned for a mean of 7.18 (range: 1–21) visits. Twenty-one (10%) were admitted to the hospital; 4 (1.9%) were related to VTE or anticoagulation complications. From a hospital perspective, a DOAC (in this case, rivaroxaban) had a total cost avoidance of $1,488.04 per VTE event, per patient. From a patient perspective, it would cost an additional $204.10 to $349.04 over 6 months, assuming no reimbursement.

VTE management in the ED has opportunities for improvement. A DOAC is a viable and cost-effective strategy for VTE treatment from a hospital perspective and, depending on patient characteristics and values, may also be an appropriate and cost-effective option from a patient perspective.

This study aimed to ascertain otolaryngologists’ current knowledge of new (e.g. apixaban, rivaroxaban) and old (e.g. warfarin) anticoagulant medications, and to provide an educational overview of new anticoagulants for use by surgeons.

A questionnaire survey was distributed across the Wessex region, UK, to ascertain the levels of knowledge of and confidence in managing patients taking various anticoagulants. In total, 50 questionnaires were completed (41 by trainees and 9 by consultants). A literature review of new anticoagulant medications was then conducted.

In general, there was poor clinical and pharmacokinetic knowledge of newly licensed anticoagulant medications. Respondents were more confident in the use of older vs newer forms of anticoagulants. This was true across all grades of doctors, but particularly at the senior level. All respondents stated that they would like to see an educational resource on anticoagulants.

Knowledge of newly licensed anticoagulation medications is poor. This study has produced an educational resource for the management of anticoagulant agents. A thorough knowledge of these drugs is essential for the acute management of bleeding patients and in peri-operative surgical planning.

There is currently little published guidance on the management of anticoagulant and antiplatelet medication in patients admitted with epistaxis. The routine practice of withholding such medication in an attempt to control the epistaxis is common in the UK. However, this practice is not evidence-based, is often unnecessary, and can be associated with significant morbidity. This study introduces a treatment algorithm for oral anticoagulant and antiplatelet therapy in epistaxis patients, validated through a completed audit cycle.

One hundred patients admitted with epistaxis to the University Hospital Southampton NHS Foundation Trust were studied via a two-audit cycle covering the implementation of a new treatment algorithm formulated jointly by the otolaryngology and haematology departments.

On admission, 58 per cent of patients were taking some form of anticoagulant or antiplatelet medication. The number of patients having such medication withheld decreased significantly between the two audits, for all drugs studied (i.e. aspirin, clopidogrel and warfarin). There was no significant increase in re-bleeding or re-admission rates between the audits.

Implementation of this treatment algorithm would help standardise management for epistaxis patients taking anticoagulant or antiplatelet drugs, and should reduce morbidity associated with unnecessary routine discontinuation of such medication.

Epistaxis can be caused or exacerbated by anticoagulant and antiplatelet therapy. This prospective study assessed the prevalence of epistaxis in patients taking anticoagulant and antiplatelet medication, and monitored differences in patients’ clinical courses.

Prospective data were collected for consecutive patients referred with epistaxis from the emergency department over a seven-month period. Emergency department records were used to investigate prevalence and referral rates.

Over the study period, 290 patients presented to the emergency department with epistaxis; this represented 0.9 per cent of all emergency attendances. Of these patients, 119 (39 per cent) were referred on to the ENT department, 62 per cent of whom were currently taking anticoagulant or antiplatelet medication. Patients taking anticoagulant and antiplatelet medication were a significantly older group (relative risk 1.50 (1.08–2.28), p = 0.01) requiring longer in-patient stays (relative risk 2.50 (1.01–4.97), p = 0.01) and more aggressive local haemostasis measures. Most patients taking warfarin had an international normalised ratio outside the appropriate range for their disease. Hypertension was not a factor in these patients’ clinical course.

Increasingly, emergency and ENT departments are being presented with epistaxis in patients taking anticoagulant or antiplatelet medication. A better understanding of such medication and its effects may enable more effective management of these patients.